IJG-08353; No of Pages 3 International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
The effectiveness of combined abdominal myomectomy and uterine artery embolization Bruce McLucas a,b,⁎, William D. Voorhees III a b c
c
Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA, USA David Geffen School of Medicine, Los Angeles, CA, USA Med Institute, West Lafayette, IN, USA
a r t i c l e
i n f o
Article history: Received 12 November 2014 Received in revised form 5 March 2015 Accepted 18 May 2015 Keywords: Embolization Laparotomy Minimally invasive gynecology Myoma Myomectomy Uterine artery embolization
a b s t r a c t Objective: To evaluate the efficacy of abdominal myomectomy after uterine artery embolization (UAE-AM) among patients with myomas. Methods: In a retrospective study, chart data were reviewed for patients attending a center in California, USA, who underwent UAE-AM between 1999 and 2012. Patients had been offered the combined procedure if the diameter of the myoma was at least 4 cm, they wished to preserve fertility, or they were candidates for a traditional abdominal myomectomy. Estimated blood loss, fluoroscopy times, and hospital stay were recorded. Follow-up data on uterine volume and fibroid size had been collected via magnetic resonance imaging or ultrasonography approximately 3–6 months after UAE-AM. Result: Overall, 20 patients underwent UAE-AM. Approximately 6 months after the procedure, the mean decrease in uterine volume was 77.33% ± 14.25% and that in myoma diameter was 46.45% ± 25.61%. Six women subsequently became pregnant; one patient had two separate pregnancies. No patient required a conversion to hysterectomy or blood transfusion, and no recurrences were reported. Conclusion: UAE-AM was found to be an effective option available to women with large myomas who wished to preserve their uterus. With the combination procedure, patients had favorable outcomes with no fibroid recurrence. Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
1. Introduction Abdominal myomectomy (AM) is the preferred alternative to hysterectomy for treatment of uterine myomas in women of reproductive age [1]. The procedure is used to remove large intramural and subserosal myomas that are thought to impede conception and can restore fertility. However, one study [2] has shown that the risk of recurrence for new myomas after AM is 50% after 5 years, with a 20% chance of subsequent surgery after 10 years. Furthermore, another study [3] has determined that risk of morbidity (including blood loss) is higher after AM than after hysterectomy. AM can be a complicated surgery, with significant blood loss and operation times, potentially resulting in a conversion to hysterectomy [4,5]. In cases for which uterine artery embolization (UAE) is not able to remove all symptoms, combining UAE with AM offers physicians an alternative that not only decreases blood loss, but also offers patients no reoccurrence [6]. AM after UAE (UAE-AM) has been offered to patients with large myomas and enlarged uteri for whom UAE alone was unlikely to relieve symptoms [7,8]. AM is also offered to patients who desire pregnancy within a short time of UAE [8]. ⁎ Corresponding author at: 450 Roxbury Dr. Ste. 275, Beverly Hills, CA 90210, USA. Tel.: +1 310 208 2442; fax: +1 310 208 2621. E-mail address: [email protected] (B. McLucas).
Previous case reports [6,9,10] have determined that the risk of blood loss is lower with UAE-AM than with AM alone; additionally, surgeons note greater ease during myoma removal. The aim of the present study was to evaluate the efficacy of UAE-AM as a treatment for selected patients with myomas. 2. Materials and methods In a retrospective chart review, data were assessed from patients attending a private practice in Beverly Hills, CA, USA, who underwent UAEAM between January 1, 1999, and December 31, 2012. Review board approval for the study was not required because the patients were offered the same procedure irrespective of study inclusion. Patient consent was not required because no data could be linked to any specific individual. Patients had been offered UAE-AM if the diameter of the myoma was at least 4 cm, they desired to retain their uterus for future fertility, or they were candidates for traditional AM. There were no exclusion factors. All patients gave written and verbal consent to undergo UAE-AM, stating that they understood the potential risks, including but not limited to early menopause, conversion to hysterectomy, blood transfusion, and possible complications during or after pregnancy. For all patients, UAE was performed on an outpatient basis by the same physician (B.M.) using a standard technique. A small incision was made in the right groin while the patient was under local anesthetic
http://dx.doi.org/10.1016/j.ijgo.2015.03.039 0020-7292/Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: McLucas B, Voorhees WD, The effectiveness of combined abdominal myomectomy and uterine artery embolization, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.03.039
2
B. McLucas, W.D. Voorhees III / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
and conscious sedation. Embolization was performed under fluoroscopic guidance using polyvinyl alcohol particles of 500 μm or larger (Cook Medical, Bloomington, IN, USA). The larger particle size was selected to ensure complete blockage of the vessel. Subtraction uterine angiography was performed to reveal stasis within the artery and to ensure that the remainder of the internal iliac arterial branches remain unchanged. The left uterine artery was similarly identified, and embolization was performed in the same way with subtraction uterine angiography to reveal stasis within the artery. In some cases, further angiography was performed to identify a collateral supply to the uterus. AM was then performed within 1 week. Approximately 3–6 months after UAE-AM, uterine volume and fibroid size were measured by magnetic resonance or ultrasonography. For the present analysis, medical and demographic data were collected via chart review of medical reports. Data were extracted on estimated blood loss, fluoroscopy times, and hospital stay. Added morbidity was defined as an increase in postoperative hospital stay, blood transfusion, or other associated complications as compared with the outcomes with AM or UAE alone. Data for outcomes after AM or UAE alone were obtained from a previous study by West et al. [11]. Patients were asked about fertility following UAE-AM by telephone or by in person interview. Statistical comparisons were made by using JMP version 9.02 (SAS Institute, Cary, NC, USA). P b 0.05 was deemed significant, indicating a 5% possibility that the difference was by random chance. 3. Results During the study period, there were 20 patients who had a planned AM within 1 week of UAE. Table 1 shows their characteristics. All patients had at least two large myomas and an enlarged uterus, which presented with bulk symptoms including pelvic pain, pressure, and menorrhagia. Table 2 shows outcomes during and after AM. Overall, six women in the study cohort became pregnant after UAEAM, one of whom had two separate pregnancies. Four of seven women who specifically desired to become pregnant after UAE-AM subsequently conceived. None of the six women who conceived had any complications during their pregnancies. The mean fluoroscopy time for the women who became pregnant was 7.53 minutes. None of the study patients experienced recurrence. Three of the 20 patients underwent a subsequent procedure (laparoscopic lysis of adhesions) after UAE-AM to relieve pain and pressure. Length of hospital stay was shorter among patients who underwent UAE-AM than among those who underwent myomectomy (Table 3). Patients who had a UAE or a UAE-AM did not require blood transfusions and had no postoperative complications, unlike patients who had only a myomectomy (Table 3). The blood transfusion rate did not differ significantly between patients who had UAE-AM and those who underwent AM alone (P = 0.190). 4. Discussion The present findings suggest that UAE-AM is an efficacious option for women and could offer better results for selected cases than does AM alone. Fewer patients undergoing UAE-AM than AM alone experience complications, such as blood loss requiring transfusion. Additionally, women who have undergone UAE-AM can subsequently become pregnant.
Table 1 Characteristics of included patients (n = 20).a Characteristic
Value (n = 20)
Age at time of procedure, y Uterine volume, cm3 Myoma diameter, cm
38.58 (23–50) 988.9 ± 694.7 9.26 ± 3.63
a
Values are given as mean (range) or mean ± SD.
Table 2 Outcomes (n = 20). Measurement
Mean ± SD
Decrease in uterine volume, %a Decrease in myoma diameter, %a Amount of myoma removed, g Hospital stay, d Blood loss, mL
77.33 ± 14.25 46.45 ± 26.51 845.17 ± 599.14 2.9 ± 3.2 56.5 ± 89.6
a
Measured approximately 3–6 months after the procedure.
In the present study, no women who underwent UAE-AM required a blood transfusion. This finding is in line with those of previous studies [5,6,12,13]. In one previous report [13], 12.5% of patients who had AM alone needed to have a blood transfusion, compared with no women who underwent UAE-AM. Although there was no significant difference in the blood transfusion rate in either the present study or the previous report [13], the sample size for both study groups was small and a trend was shown toward reduced risk of blood transfusion in patients undergoing UAE-AM as compared with those who underwent AM alone. Furthermore, the estimated blood loss for patients who had AM alone has been reported as 227–365 mL [4,14,15], which is more than the 56.5 mL observed for patients undergoing UAE-AM in the present study. In the present study, an average of 845.17 g of myoma tissue was removed, which is much larger than the average of 668 g removed by AM alone in a previous study [11]. The present cohort had an average reduction of 46.5% in myoma diameter at approximately 4.6 months after UAE-AM, which is similar to the 50% myoma shrinkage previously observed among patients who underwent UAE alone [16]. Other studies have reported an average hospital stay ranging from 3.6 to 4 days for women who underwent AM alone [4,13,14]. Patients undergoing UAE-AM in the present study had a comparatively shorter hospital stay of 2.9 days. Often in cases of heavy blood loss during AM, conversion to hysterectomy occurs. However, none of the women who underwent UAE-AM in the present study experienced complications such as conversion to hysterectomy, blood transfusions, or infection. The present data are similar to those reported in a previous study of AM, for which the average hospital stay was 3.6 days and 12% received postoperative blood transfusions [13]. Although UAE-AM might seem to be a more expensive treatment option than AM alone, the present results suggest that performing both procedures concurrently may reduce the possibility of additional costs owing to prolonged hospital stay, complications, and subsequent surgery. In such instances, UAE-AM may represent a more costeffective solution for women with large fibroids in terms of both the cost of additional procedures and the cost of time off work for disability or repeat hospital admission. Laparoscopic myomectomy is often used for large fibroids, but could have a high blood transfusion rate [12]. In one study [17], 22% of patients with fibroids heavier than 80 g needed a blood transfusion, compared with none among patients who underwent UAE-AM in the present study. More recently, laparoscopic myomectomy has been subjected to scrutiny with regard to the risk of dissemination of cancerous tissue via Table 3 Comparison of complications after abdominal myomectomy, UAE, and UAE-AM.a Complication
Myomectomy (n = 16)
UAE (n = 32)
UAE-AM (n = 20)
Mean hospital stay, d Patients who received a transfusion, % Patients with postoperative complications, %b
3.6 12 25
1.1 0 0
2.9 0 0
Abbreviation: UAE, uterine artery embolization; UAE-AM, abdominal myomectomy after uterine artery embolization. a Data on myomectomy and UAE were taken from ref. [11]. b Including small bowel laceration, ileus, and phlebitis.
Please cite this article as: McLucas B, Voorhees WD, The effectiveness of combined abdominal myomectomy and uterine artery embolization, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.03.039
B. McLucas, W.D. Voorhees III / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
fibroid morcellation [18]. The Society of Gynecologic Oncology estimates this risk to be between 0.1% and 0.25% [19]. Thus, UAE-AM may also be a better choice for women with large fibroids where leiomyosarcoma cannot be definitively ruled out. Traditionally, UAE has been considered a contraindication for women who want to preserve their fertility owing to radiation exposure among other complications [20]. Pregnancy after UAE is not uncommon, occurring in up to 48% of women undergoing UAE who report a wish to conceive [21]. In the present study, six women achieved pregnancy after UAE-AM, and one patient achieved two separate pregnancies. The mean fluoroscopy time for women who became pregnant was 7.53 minutes, which is much shorter than reported in studies of UAE alone [20,22]. The present study suggests that the amount of radiation is safe because 30% of the women were able to conceive. Although the pregnancy rate was lower than in a previous study [13], the present sample was small and additional data are needed to make further conclusions. Some complications of UAE, such as abnormal placentation, could affect a patient’s ability to achieve a viable pregnancy [23]. In these cases, myomectomy combined with embolization might facilitate a subsequent pregnancy that is otherwise unlikely [8]. Approximately 7% of patients—almost all of whom are older than 45 years—report amenorrhea after UAE [24], which can be an indication of premature ovarian failure due to inadvertent non-target embolization of the ovarian circulation. More evidence is needed to determine whether this rare complication occurs in younger women. The present study has some limitations. The number of patients was small; with a larger sample size, more accuracy would be seen in the average measurements collected and compared. Additionally, the study makes comparisons with other retrospective study data collected previously. Thus, technical differences and confounding factors could have contributed to the disparities. In a follow-up study, data from patients undergoing AM alone and UAE-AM should be examined and compared to eliminate any confounding variables. In summary, UAE-AM has been shown to be an effective option available to women with large myomas exceeding 4 cm who desire preservation of their uterus for future fertility. With this combination procedure, patients experienced no additional morbidity and had better outcomes as compared with AM alone. Conflict of interest The authors have no conflicts of interest. References [1] Seracchioli R, Rossi S, Govoni F, Rossi E, Venturoli S, Bulletti C, et al. Fertility and obstetric outcome after laparoscopic myomectomy of large myomata: a randomized comparison with abdominal myomectomy. Hum Reprod 2000;15(12):2663–8. [2] Stewart EA, Faur AV, Wise LA, Reilly RJ, Harlow BL. Predictors of subsequent surgery for uterine leiomyomata after abdominal myomectomy. Obstet Gynecol 2002;99(3): 426–32.
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[3] LaMorte AI, Lalwani S, Diamond MP. Morbidity associated with abdominal myomectomy. Obstet Gynecol 1993;82(6):897–900. [4] Sawin SW, Pilevsky ND, Berlin JA, Barnhart KT. Comparability of perioperative morbidity between abdominal myomectomy and hysterectomy for women with uterine leiomyomas. Am J Obstet Gynecol 2000;183(6):1448–55. [5] Butori N, Tixier H, Filipuzzi L, Mutamba W, Guiu B, Cercueil JP, et al. Interest of uterine artery embolization with gelatin sponge particles prior to myomectomy for large and/or multiple fibroids. Eur J Radiol 2011;79(1):1–6. [6] Malartic C, Morel O, Fargeaudou Y, Le Dref O, Fazel A, Barranger E, et al. Conservative two-step procedure including uterine artery embolization with embosphere and surgical myomectomy for the treatment of multiple fibroids: preliminary experience. Eur J Radiol 2012;81(1):1–5. [7] Bradley EA, Reidy JF, Forman RG, Jarosz J, Braude PR. Transcatheter uterine artery embolisation to treat large uterine fibroids. Br J Obstet Gynaecol 1998;105(2): 235–40. [8] Nabeshima H, Murakami T, Sato Y, Terada Y, Yaegashi N, Okamura K. Successful pregnancy after myomectomy using preoperative adjuvant uterine artery embolization. Tohoku J Exp Med 2003;200(3):145–9. [9] Paxton BE, Lee JM, Kim HS. Treatment of intrauterine and large pedunculated subserosal leiomyomata with sequential uterine artery embolization and myomectomy. J Vasc Interv Radiol 2006;17(12):1947–50. [10] Dumousset E, Chabrot P, Rabischong B, Mazet N, Nasser S, Darcha C, et al. Preoperative uterine artery embolization (PUAE) before uterine fibroid myomectomy. Cardiovasc Intervent Radiol 2008;31(3):514–20. [11] West S, Ruiz R, Parker WH. Abdominal myomectomy in women with very large uterine size. Fertil Steril 2006;85(1):36–9. [12] Ngeh N, Belli AM, Morgan R, Manyonda I. Pre-myomectomy uterine artery embolisation minimises operative blood loss. BJOG 2004;111(10):1139–40. [13] McLucas B, Adler L. Uterine fibroid embolization compared with myomectomy. Int J Gynecol Obstet 2001;74(3):297–9. [14] McLucas B, Adler L, Perrella R. Uterine fibroid embolization: nonsurgical treatment for symptomatic fibroids. J Am Coll Surg 2001;192(1):95–105. [15] Advincula AP, Xu X, Goudeau 4th S, Ransom SB. Robot-assisted laparoscopic myomectomy versus abdominal myomectomy: a comparison of short-term surgical outcomes and immediate costs. J Minim Invasive Gynecol 2007;14(6):698–705. [16] Volkers NA, Hehenkamp WJ, Birnie E, Ankum WM, Reekers JA. Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: 2 years’ outcome from the randomized EMMY trial. Am J Obstet Gynecol 2007; 196(6):519.e1–519.e11. [17] Wang CJ, Yuen LT, Lee CL, Kay N, Soong YK. Laparoscopic myomectomy for large uterine fibroids. A comparative study. Surg Endosc 2006;20(9):1427–30. [18] Cohen SL, Einarsson JI, Wang KC, Brown D, Boruta D, Scheib SA, et al. Contained power morcellation within an insufflated isolation bag. Obstet Gynecol 2014; 124(3):491–7. [19] Goff BA. SGO not soft on morcellation: risks and benefits must be weighed. Lancet Oncol 2014;15(4):e148. [20] Lupattelli T, Basile A, Garaci FG, Simonetti G. Percutaneous uterine artery embolization for the treatment of symptomatic fibroids: current status. Eur J Radiol 2005; 54(1):136–47. [21] McLucas B. Pregnancy following uterine artery embolization: an update. Minim Invasive Ther Allied Technol 2013;22(1):39–44. [22] Mara M, Fucikova Z, Maskova J, Kuzel D, Haakova L. Uterine fibroid embolization versus myomectomy in women wishing to preserve fertility: preliminary results of a randomized controlled trial. Eur J Obstet Gynecol Reprod Biol 2006;126(2): 226–33. [23] Mara M, Horak P, Kubinova K, Dundr P, Belsan T, Kuzel D. Hysteroscopy after uterine fibroid embolization: evaluation of intrauterine findings in 127 patients. J Obstet Gynaecol Res 2012;38(5):823–31. [24] Spies JB, Myers ER, Worthington-Kirsch R, Mulgund J, Goodwin S, Mauro M, et al. The FIBROID Registry: symptom and quality-of-life status 1 year after therapy. Obstet Gynecol 2005;106(6):1309–18.
Please cite this article as: McLucas B, Voorhees WD, The effectiveness of combined abdominal myomectomy and uterine artery embolization, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.03.039
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
The effectiveness of combined abdominal myomectomy and uterine artery embolization Bruce McLucas a,b,⁎, William D. Voorhees III a b c
c
Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA, USA David Geffen School of Medicine, Los Angeles, CA, USA Med Institute, West Lafayette, IN, USA
a r t i c l e
i n f o
Article history: Received 12 November 2014 Received in revised form 5 March 2015 Accepted 18 May 2015 Keywords: Embolization Laparotomy Minimally invasive gynecology Myoma Myomectomy Uterine artery embolization
a b s t r a c t Objective: To evaluate the efficacy of abdominal myomectomy after uterine artery embolization (UAE-AM) among patients with myomas. Methods: In a retrospective study, chart data were reviewed for patients attending a center in California, USA, who underwent UAE-AM between 1999 and 2012. Patients had been offered the combined procedure if the diameter of the myoma was at least 4 cm, they wished to preserve fertility, or they were candidates for a traditional abdominal myomectomy. Estimated blood loss, fluoroscopy times, and hospital stay were recorded. Follow-up data on uterine volume and fibroid size had been collected via magnetic resonance imaging or ultrasonography approximately 3–6 months after UAE-AM. Result: Overall, 20 patients underwent UAE-AM. Approximately 6 months after the procedure, the mean decrease in uterine volume was 77.33% ± 14.25% and that in myoma diameter was 46.45% ± 25.61%. Six women subsequently became pregnant; one patient had two separate pregnancies. No patient required a conversion to hysterectomy or blood transfusion, and no recurrences were reported. Conclusion: UAE-AM was found to be an effective option available to women with large myomas who wished to preserve their uterus. With the combination procedure, patients had favorable outcomes with no fibroid recurrence. Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
1. Introduction Abdominal myomectomy (AM) is the preferred alternative to hysterectomy for treatment of uterine myomas in women of reproductive age [1]. The procedure is used to remove large intramural and subserosal myomas that are thought to impede conception and can restore fertility. However, one study [2] has shown that the risk of recurrence for new myomas after AM is 50% after 5 years, with a 20% chance of subsequent surgery after 10 years. Furthermore, another study [3] has determined that risk of morbidity (including blood loss) is higher after AM than after hysterectomy. AM can be a complicated surgery, with significant blood loss and operation times, potentially resulting in a conversion to hysterectomy [4,5]. In cases for which uterine artery embolization (UAE) is not able to remove all symptoms, combining UAE with AM offers physicians an alternative that not only decreases blood loss, but also offers patients no reoccurrence [6]. AM after UAE (UAE-AM) has been offered to patients with large myomas and enlarged uteri for whom UAE alone was unlikely to relieve symptoms [7,8]. AM is also offered to patients who desire pregnancy within a short time of UAE [8]. ⁎ Corresponding author at: 450 Roxbury Dr. Ste. 275, Beverly Hills, CA 90210, USA. Tel.: +1 310 208 2442; fax: +1 310 208 2621. E-mail address: [email protected] (B. McLucas).
Previous case reports [6,9,10] have determined that the risk of blood loss is lower with UAE-AM than with AM alone; additionally, surgeons note greater ease during myoma removal. The aim of the present study was to evaluate the efficacy of UAE-AM as a treatment for selected patients with myomas. 2. Materials and methods In a retrospective chart review, data were assessed from patients attending a private practice in Beverly Hills, CA, USA, who underwent UAEAM between January 1, 1999, and December 31, 2012. Review board approval for the study was not required because the patients were offered the same procedure irrespective of study inclusion. Patient consent was not required because no data could be linked to any specific individual. Patients had been offered UAE-AM if the diameter of the myoma was at least 4 cm, they desired to retain their uterus for future fertility, or they were candidates for traditional AM. There were no exclusion factors. All patients gave written and verbal consent to undergo UAE-AM, stating that they understood the potential risks, including but not limited to early menopause, conversion to hysterectomy, blood transfusion, and possible complications during or after pregnancy. For all patients, UAE was performed on an outpatient basis by the same physician (B.M.) using a standard technique. A small incision was made in the right groin while the patient was under local anesthetic
http://dx.doi.org/10.1016/j.ijgo.2015.03.039 0020-7292/Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: McLucas B, Voorhees WD, The effectiveness of combined abdominal myomectomy and uterine artery embolization, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.03.039
2
B. McLucas, W.D. Voorhees III / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
and conscious sedation. Embolization was performed under fluoroscopic guidance using polyvinyl alcohol particles of 500 μm or larger (Cook Medical, Bloomington, IN, USA). The larger particle size was selected to ensure complete blockage of the vessel. Subtraction uterine angiography was performed to reveal stasis within the artery and to ensure that the remainder of the internal iliac arterial branches remain unchanged. The left uterine artery was similarly identified, and embolization was performed in the same way with subtraction uterine angiography to reveal stasis within the artery. In some cases, further angiography was performed to identify a collateral supply to the uterus. AM was then performed within 1 week. Approximately 3–6 months after UAE-AM, uterine volume and fibroid size were measured by magnetic resonance or ultrasonography. For the present analysis, medical and demographic data were collected via chart review of medical reports. Data were extracted on estimated blood loss, fluoroscopy times, and hospital stay. Added morbidity was defined as an increase in postoperative hospital stay, blood transfusion, or other associated complications as compared with the outcomes with AM or UAE alone. Data for outcomes after AM or UAE alone were obtained from a previous study by West et al. [11]. Patients were asked about fertility following UAE-AM by telephone or by in person interview. Statistical comparisons were made by using JMP version 9.02 (SAS Institute, Cary, NC, USA). P b 0.05 was deemed significant, indicating a 5% possibility that the difference was by random chance. 3. Results During the study period, there were 20 patients who had a planned AM within 1 week of UAE. Table 1 shows their characteristics. All patients had at least two large myomas and an enlarged uterus, which presented with bulk symptoms including pelvic pain, pressure, and menorrhagia. Table 2 shows outcomes during and after AM. Overall, six women in the study cohort became pregnant after UAEAM, one of whom had two separate pregnancies. Four of seven women who specifically desired to become pregnant after UAE-AM subsequently conceived. None of the six women who conceived had any complications during their pregnancies. The mean fluoroscopy time for the women who became pregnant was 7.53 minutes. None of the study patients experienced recurrence. Three of the 20 patients underwent a subsequent procedure (laparoscopic lysis of adhesions) after UAE-AM to relieve pain and pressure. Length of hospital stay was shorter among patients who underwent UAE-AM than among those who underwent myomectomy (Table 3). Patients who had a UAE or a UAE-AM did not require blood transfusions and had no postoperative complications, unlike patients who had only a myomectomy (Table 3). The blood transfusion rate did not differ significantly between patients who had UAE-AM and those who underwent AM alone (P = 0.190). 4. Discussion The present findings suggest that UAE-AM is an efficacious option for women and could offer better results for selected cases than does AM alone. Fewer patients undergoing UAE-AM than AM alone experience complications, such as blood loss requiring transfusion. Additionally, women who have undergone UAE-AM can subsequently become pregnant.
Table 1 Characteristics of included patients (n = 20).a Characteristic
Value (n = 20)
Age at time of procedure, y Uterine volume, cm3 Myoma diameter, cm
38.58 (23–50) 988.9 ± 694.7 9.26 ± 3.63
a
Values are given as mean (range) or mean ± SD.
Table 2 Outcomes (n = 20). Measurement
Mean ± SD
Decrease in uterine volume, %a Decrease in myoma diameter, %a Amount of myoma removed, g Hospital stay, d Blood loss, mL
77.33 ± 14.25 46.45 ± 26.51 845.17 ± 599.14 2.9 ± 3.2 56.5 ± 89.6
a
Measured approximately 3–6 months after the procedure.
In the present study, no women who underwent UAE-AM required a blood transfusion. This finding is in line with those of previous studies [5,6,12,13]. In one previous report [13], 12.5% of patients who had AM alone needed to have a blood transfusion, compared with no women who underwent UAE-AM. Although there was no significant difference in the blood transfusion rate in either the present study or the previous report [13], the sample size for both study groups was small and a trend was shown toward reduced risk of blood transfusion in patients undergoing UAE-AM as compared with those who underwent AM alone. Furthermore, the estimated blood loss for patients who had AM alone has been reported as 227–365 mL [4,14,15], which is more than the 56.5 mL observed for patients undergoing UAE-AM in the present study. In the present study, an average of 845.17 g of myoma tissue was removed, which is much larger than the average of 668 g removed by AM alone in a previous study [11]. The present cohort had an average reduction of 46.5% in myoma diameter at approximately 4.6 months after UAE-AM, which is similar to the 50% myoma shrinkage previously observed among patients who underwent UAE alone [16]. Other studies have reported an average hospital stay ranging from 3.6 to 4 days for women who underwent AM alone [4,13,14]. Patients undergoing UAE-AM in the present study had a comparatively shorter hospital stay of 2.9 days. Often in cases of heavy blood loss during AM, conversion to hysterectomy occurs. However, none of the women who underwent UAE-AM in the present study experienced complications such as conversion to hysterectomy, blood transfusions, or infection. The present data are similar to those reported in a previous study of AM, for which the average hospital stay was 3.6 days and 12% received postoperative blood transfusions [13]. Although UAE-AM might seem to be a more expensive treatment option than AM alone, the present results suggest that performing both procedures concurrently may reduce the possibility of additional costs owing to prolonged hospital stay, complications, and subsequent surgery. In such instances, UAE-AM may represent a more costeffective solution for women with large fibroids in terms of both the cost of additional procedures and the cost of time off work for disability or repeat hospital admission. Laparoscopic myomectomy is often used for large fibroids, but could have a high blood transfusion rate [12]. In one study [17], 22% of patients with fibroids heavier than 80 g needed a blood transfusion, compared with none among patients who underwent UAE-AM in the present study. More recently, laparoscopic myomectomy has been subjected to scrutiny with regard to the risk of dissemination of cancerous tissue via Table 3 Comparison of complications after abdominal myomectomy, UAE, and UAE-AM.a Complication
Myomectomy (n = 16)
UAE (n = 32)
UAE-AM (n = 20)
Mean hospital stay, d Patients who received a transfusion, % Patients with postoperative complications, %b
3.6 12 25
1.1 0 0
2.9 0 0
Abbreviation: UAE, uterine artery embolization; UAE-AM, abdominal myomectomy after uterine artery embolization. a Data on myomectomy and UAE were taken from ref. [11]. b Including small bowel laceration, ileus, and phlebitis.
Please cite this article as: McLucas B, Voorhees WD, The effectiveness of combined abdominal myomectomy and uterine artery embolization, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.03.039
B. McLucas, W.D. Voorhees III / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
fibroid morcellation [18]. The Society of Gynecologic Oncology estimates this risk to be between 0.1% and 0.25% [19]. Thus, UAE-AM may also be a better choice for women with large fibroids where leiomyosarcoma cannot be definitively ruled out. Traditionally, UAE has been considered a contraindication for women who want to preserve their fertility owing to radiation exposure among other complications [20]. Pregnancy after UAE is not uncommon, occurring in up to 48% of women undergoing UAE who report a wish to conceive [21]. In the present study, six women achieved pregnancy after UAE-AM, and one patient achieved two separate pregnancies. The mean fluoroscopy time for women who became pregnant was 7.53 minutes, which is much shorter than reported in studies of UAE alone [20,22]. The present study suggests that the amount of radiation is safe because 30% of the women were able to conceive. Although the pregnancy rate was lower than in a previous study [13], the present sample was small and additional data are needed to make further conclusions. Some complications of UAE, such as abnormal placentation, could affect a patient’s ability to achieve a viable pregnancy [23]. In these cases, myomectomy combined with embolization might facilitate a subsequent pregnancy that is otherwise unlikely [8]. Approximately 7% of patients—almost all of whom are older than 45 years—report amenorrhea after UAE [24], which can be an indication of premature ovarian failure due to inadvertent non-target embolization of the ovarian circulation. More evidence is needed to determine whether this rare complication occurs in younger women. The present study has some limitations. The number of patients was small; with a larger sample size, more accuracy would be seen in the average measurements collected and compared. Additionally, the study makes comparisons with other retrospective study data collected previously. Thus, technical differences and confounding factors could have contributed to the disparities. In a follow-up study, data from patients undergoing AM alone and UAE-AM should be examined and compared to eliminate any confounding variables. In summary, UAE-AM has been shown to be an effective option available to women with large myomas exceeding 4 cm who desire preservation of their uterus for future fertility. With this combination procedure, patients experienced no additional morbidity and had better outcomes as compared with AM alone. Conflict of interest The authors have no conflicts of interest. References [1] Seracchioli R, Rossi S, Govoni F, Rossi E, Venturoli S, Bulletti C, et al. Fertility and obstetric outcome after laparoscopic myomectomy of large myomata: a randomized comparison with abdominal myomectomy. Hum Reprod 2000;15(12):2663–8. [2] Stewart EA, Faur AV, Wise LA, Reilly RJ, Harlow BL. Predictors of subsequent surgery for uterine leiomyomata after abdominal myomectomy. Obstet Gynecol 2002;99(3): 426–32.
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Please cite this article as: McLucas B, Voorhees WD, The effectiveness of combined abdominal myomectomy and uterine artery embolization, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.03.039
